QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
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Initial Comments:

This report is the result of an unannounced onsite complaint investigation (CHL18C624J) conducted on December 17, 2018, and December 23, 2018, at Conemaugh Memorial Medical Center completed on March 7, 2019. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.

Plan of Correction:


Name - Component - 00
107.11 Principle
The medical staff shall develop and adopt, subject to the approval of the governing body, a set of bylaws, rules and regulations.


Based on a review of medical record (MR), facility documents and interview with staff (EMP), it was determined that Conemaugh Memorial Medical Center failed to follow their adopted Medical Staff Rules and Regulations related to consultations in one of one patient (MR1).

Conemaugh Memorial Medical Center, Medical Staff Rules and Regulations, dated October 28, 2018, revealed, "... Appendix 'B'-Rules and Regulations ...Article II-Medical Records ... 2.6 Consultations ... Consultations must be seen by the consulted service within 12 hours or if the consult is ordered after noon by noon the following day. The consult may be ordered for 24 hours if the ordering physician desires. In the event that the attending physician requires STAT or urgent consultation, the attending physician must communicate directly with the consulting physician. ... If the patient is initially seen in consultation by a resident physician, physician assistant, or nurse practitioner, that provider must discuss the patient with their supervising physician promptly after seeing the patient and document said discussion and recommendations. The attending consultant must see the patient within 24 hours. (An exception is made for the palliative care service. A consult completed by the physician assistant or CRNP is considered complete. If a physician cannot perform a consult within the specified time frame, he or she must personally notify the requesting physician so that another consultant or other arragements can be requested. If the patient is discharged prior to being seen in consultation, said consultation is considered to have been cancelled by the discharging physician and is no longer necessary. ... ."

Findings Include:

1. MR1 electronic physician orders revealed, "... Consult to Hematology ... 12/7/18 1430 ... Consult to Hematology ... 12/05/18 2041 ... ."

2. MR1 revealed, "... Consult to Hematology: Once, Status: Canceled 12/05/18 2041 ... Consult Priority: Within 24 hours. Reason for Consult: superficial thrombophlebitis. Did you contact the consultant? No ... ."

3. MR1 Hematology Consult dated December 7, 2018, at 3:27 PM revealed, "... Reason for Consult: Superficial thrombophlebitis ... Assessment and Plan: Recurrent episodes of syncope. Likely vasovagal. Possible coarctation of the aorta, repeat echo and possible CTA postpartum ... ."

Telephone interview with EMP1 on March 7, 2019, at approximately 2:40 PM revealed, "... The consult was ordered on December 5, 2018, but the physician did not see the patient until December 7, 2018."

Plan of Correction:

1. Health Information Services Department will be responsible for reporting results of delinquent consult timeliness to Senior Physician Leadership beginning March 25, 2019. The Chief Medical Officer will provide education to the Medical Executive Committee on March 18, 2019.

2. Reporting period is to be each work day, Monday through Friday. With each Monday, or day following a holiday, reviewing "timeliness" report for any non-compliant consult orders.

3. Reporting results each traditional work day via email to Chief Medical Officer (CMO) and or Vice President of Medical Affairs (VP MA) or their designee. CMO and or VP MA (or designee) will be responsible for physician review of Medical Staff Rules and Regulations. Also CMO and or VP MA will direct physician for process education in electronic health record (EHR) environment.

4. A "Consult" Compliance report will be created capturing compliance rates by individual physician. This report, along with the daily reporting information will be supplied to Senior Physician Leadership for their reporting to Medical Executive Committee meetings (April 15, May 20, June 17, and July 15, 2019)
Results will be reported out at Performance Excellence (PE) Steering Committee for four consecutive months (April 10, May 8, June 12, and July 10, 2019) and at Performance Excellence Committee (PEC) for four consecutive months, April 17, May 15, June 19, and July 17, 2019.

All Nurse managers will be educated at Nurse Manager meeting on April 4, 2019 by Nurse Manager Rose 7 PCU and Director of Nursing Practice.

All Nurse managers will educate their floor staff by May 4, 2019 and maintain record of their employees receiving education.

Education to include: Ensure Epic (Electronic Health Record) work list is used with documenting notification of consultation to provider, date, and time. Ensure the consulting physician is listed on patient's treatment team in Epic.

Audits to be completed on nursing departments to verify consults are being notified. Ten audits per month per Nurse Manager on all in patient (IP) units will be performed. (Med Surg 7, Ashman 10, Rose 10, Ashman 9, Rose 9, Ashman 8, Rose 8, Ashman 7, Rose 7 PCU, Ashman 6 ICU, Rose 6 ICU, Maternity, RICN, Peds, Womens Services, Good Sam 4, Good Sam 6, Adult Psych, and Gero Psych) The Nurse Manager Rose 7 PCU will be responsible to collect, compile and maintain the data.

Results will be reported out at PE Steering Committee for four consecutive months (April 10, May 8, June 12, and July 10, 2019) and at PEC for four consecutive months (April 17, May 15, June 19, and July 17, 2019).

This is the process that will be used to make sure that echocardiogram studies are read, saved and sent timely to the patient's record to visualize.

A Saved status button has been added to the echocardiogram reading work list used for compliance reports to visualize results that are not finalized. When this occurs the reading physician will be contacted to complete the work task. Failures will be tracked and results will be reported out at PE Steering for four consecutive months (April 10, May 8, June 12, and July 10, 2019) and at PEC for four consecutive months (April 17, May 15, June 19, and July 17, 2019).